HomeMy Public PortalAboutTreasure ReportsWAIVER OF REPORT
(Section 106.07(7), F.S.)
(PLEASE TYPE)
]ko 5 FYI ,
Name
35a y C9 a In l ( au
Address
Office Sought
(Su 417./ F� 3�y"
City State Zip Code
Candidate ❑ Political Committee ❑ Party Executive Committee
NOTE: This form does not apply to an electioneering communications organization (ECO). An ECO must file a report (not a
waiver) that no reportable contributions or expenditures were made dudng the reporting period (s. 106.0703(6), F.S.).
❑ Check here if address has changed since last report. ❑ Check here if PC has DISBANDED and will no longer file
reports.
TYPE OF REPORT (Check Appropriate Box and Complete Applicable Line beneath Box)
❑ MONTHLY REPORT ❑ PRIMARY ELECTION X GENERAL ELECTION ❑ OTHER REPORT TYPE
Indicate report # Indicate report # Indicate report # Indicate report type and #
M P G_L_ as applicable:
❑ TERMINATION REPORT ❑ SPECIAL ELECTION
NOTIFICATION OF NO ACTIVITY IN CAMPAIGN ACCOUNT FOR THE REPORTING PERIOD OF
ate
X
Signature
Date
REQUIRED SIGNATURES FOR: Candidates:
Candidate and Campaign Treasurer or Deputy Treasurer (s. 106.07(5), F.S.)
Political Committees:
Chairman and Campaign Treasurer or Deputy Treasurer (s. 106.07(5), F.S.)
Party Executive Committees:
Treasurer and Chairman (s. 106.29(2), F.S.)
Except as noted above for an ECO, in any reporting period when there has been no activity in the account (no funds expended or
received) the filing of the required report is waived. However, the filing officer must be notified in writing on the prescribed
reporting date that no report is being filed.
DS -DE 87 (Rev. 06115)
(1)
(2)
CAMPAIGN
and street)
City, State, Zip Code
❑ Check here if address has changed
(4) Check appropriate box(es):
Candidate Office Sought: QA
❑ Political Committee (PC)
❑ Electioneering Communications Org. (ECO)
❑ Party Executive Committee (PTY)
❑ Independent Expenditure (IE) (also covers an
individual making electioneering communications)
RER'S REPORT SUMMARY
OFFICE USE ONLY
(3) ID Number:
❑ Check here if PC or ECO has disbanded
❑ Check here if PTY has disbanded
❑ Check here if no other IE or EC reports will be filed
(5) Report Identifiers
Cover Period: From d / / To a /'_1 (� / / Report Type:
Original Amendment ❑ Special Election Report
(6) Contributions This Report (7) Expenditures This Report
Monetary
Cash & Checks $_ • _ Expenditures $ O
Loans $
Total Monetary $
In -Kind $ 7_ . y D
(9) TOTAL Monetary Contributions To Date
$ 291D
Transfers to
Office Account $
Total Monetary $ ,
(8) Other Distributions
$ ,
(10) TOTAL Monetary Expenditures To Date
$
(11) Certification
It is a first degree misdemeanor for any person to falsify a public record (ss. 839.13, F.S.)
I certify that I hav examined this report Td it (iis true, conect, and complette�_ , � �n
(Type name�ID01 5 1 r L r l f W (Type name) J ILbf)'tvl.5 1 r� , ll47*
❑ Individual (only for IE KTreasurer ❑ Deputy Tre surer 9 Candidate ❑ Chairperson (only for PC and PTY)
or electioneering comm.)
Signature Si' e
"�-"� " t^."• 1101 SEE REVERSE FOR INSTRUCTIONS
Instructions for Campaign Treasurer's Report Summary
(1)
Name: full name of the candidate, political committee, party executive committee, electioneering
communications organization, or individual making an independent expenditure or electioneering
communication.
(2)
Address: the full address or post office box, city, state, and zip code.
_ Check the box if the address has changed since the last report filed.
(3)
ID Number: identification number assigned by the filing officer.
4
Check the appropriate box(es).
(5)
Report Identifiers
Cover Period: the dates this report covers (i.e., From 1/1/15 To 1/31/55). Important: use the appropriate
cover period dates as published by the riling officer.
Report Type: refer to the filing officer's calendar of reporting dates for the correct codes to be used for
each reporting period. If report is for a special election add "S" in front of the report code (i.e., SG3).
Check one of the appropriate boxes:
Original: first report filed for this reporting period.
Amendment: must summarize only contributions/fund transfers and expenditures/distributions being
reported as additions or deletions. Read instructions for sequence numbers and amendment types on
the back of Forms DS -DE 13A and 14A.
= Special Election Report: Important: once a special election report is filed, the entity is required to file all
remaining reports due for the special election.
(6)
Contributions This Report:
Cash and Checks: total amount for this reporting period.
Loans: total amount for this reporting period.
Total Monetary: sum of Cash and Checks and Loans.
In -Kind: the fair market value of the in-kind contribution at the time it is given for this reporting period.
(7)
Expenditures This Report:
Monetary Expenditures: total amount of monetary expenditures for this reporting period.
Transfers to Office Account: total amount transferred to an office account by elected candidates only.
Total Monetary: sum of Monetary Expenditures and Transfers to Office Account.
(8)
Other Distributions: the total amount of goods and services contributed to a candidate or other
committee by a PC, ECO, or PTY.
(9)
TOTAL Monetary Contributions To Date: the amount of total monetary contributions to date.
Candidates keep cumulative totals from the time the campaign depository is opened through the
termination report.
(10)
TOTAL Monetary Expenditures To Date: the amount of total monetary expenditures to date.
Candidates keep cumulative totals from the time the campaign depository is opened through the
termination report.
(11)
Type or print the required officer's name and have them sign the report:
Candidate report: treasurer and candidate must sign.
PC report: treasurer and chairperson must sign.
_ PTY report: treasurer and chairperson must sign.
= ECO report: organization's treasurer must sign.
— HE or EC report: individual must sign (this applies when an individual acts alone to make these
expenditures)
AMENDMENT REPORTS: An amendment report summary should summarize only
contributions, expenditures, distributions, & fund transfers being reported as additions or
deletions. Read the instructions for the sequence number & amendment type fields on
the back of forms DS -DE 13, 14, 14A and 94.
CAMPAIGN TREASURER'S REPORT—ITEMIZED CONTRIBUTIONS
(1) Name Un (2) I.D. Number
(3) Cover Period / 1 / �4through oc / a y / (4) Page
of /
US -VE M kRev. 11113) SEE REVERSE FOR INSTRUCTIONS AND CODE VALUES
(5) (7) (6) (9) (10) (11)
Date Full Name
(6) (Last, Suffix, First, Middle)
Sequence Street Address& Contributor Contribution In-kind
Number Ci ,State, Zi Code T e Occu ation T e Descri don Amendment
(12)
Amount
5-vki/1/0oov,
CAS
US -VE M kRev. 11113) SEE REVERSE FOR INSTRUCTIONS AND CODE VALUES
INSTRUCTIONS FOR CAMPAIGN TREASURER'S REPORT - ITEMIZED CONTRIBUTIONS
(1) Candidate's full name or name of the political committee (PC), electioneering communications organizations
(ECO) or party executive committee (PTY).
(2) The identification number assigned by the filing officer.
(3) Cover period dates (e.g., 1/1/15 through 1/31/15). (See fling officer's reporting dates calendar for
appropriate year and cover periods.)
(4) Page numbers (e.g., 1 of 3 ).
(5) Date contribution was RECEIVED (Month/Day/Year).
(6) Sequence Number— Each detail line shall have a sequence number assigned to it. Sequence numbers
are to be assigned within each reporting period and for each type of detail line. Thus the report type, detail
line type, and sequence number will combine to uniquely identify a specific contribution, expenditure,
distribution or fund transfer. This method of unique identification is required for responding to requests from
the filing officer and for reporting amendments.
For example, a M1 report having 75 contributions would use sequence numbers 1 through 75. The next
report (M2), comprised of 40 contributions would use sequence numbers 1 through 40. Contributions on
amended M1 reports would begin with sequence number 76 and on amended M2 reports would begin with
sequence number 41. See the Amendment Type instructions below.
(7) Type full name and address of contributor (including city, state and zip code).
(8) Enter the type of contributor using one of the following codes:
Occupation of contributor for contributions over $100 only. (If a business, please indicate nature of
business.)
I
Individual
CAS
B
Business
also includes corporations, organizations, groups, etc.
E
Electioneering Communications Organizations
INK
F
Political Committee
federal or state
P
Political Parties
(includes federal, state and county executive
committees
O
Other
(e.g., candidate surplus funds to party, etc.
S
Candidate to Self
Receipts
(9) Enter Contribution Type using one of the following codes:
NOTE: Cash Includes cash and cashier's checks.
Code
Description
CAS
Cash or Cashier's Check
CHE
Check
COF
Carryover Funds from Previous Campaign
INK
In -Kind
INT
Interest
LOA
Loan
MO
Money Order
MUCMulti
le Uniform Contributions
RCT
Other
Receipts
REF
Refund (Negative
Amount Only)
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